Provider Demographics
NPI:1548354053
Name:SHANLEY, LAWRENCE KETRICK (RPH)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:KETRICK
Last Name:SHANLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GORMAN WAY
Mailing Address - Street 2:PO BOX 86
Mailing Address - City:PERU
Mailing Address - State:NY
Mailing Address - Zip Code:12972-0086
Mailing Address - Country:US
Mailing Address - Phone:518-643-2318
Mailing Address - Fax:518-643-0010
Practice Address - Street 1:2 GORMAN WAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972-0086
Practice Address - Country:US
Practice Address - Phone:518-643-2318
Practice Address - Fax:518-643-0010
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00619172Medicaid
NY3342499OtherNCPDP
NY016918OtherPHARMACY LICENSE
NYAP9569584OtherDEA
NY00619172Medicaid